Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

Could the contraceptive counselling improve contraceptive choice after abortion? A multicentric study to evaluate patients' perception

INTRODUCTION

24 % of abortion in Italy are repeated procedure. The cause of repeated abortion can be traced back to the inadequacy of the contraceptive counseling during the previous admission or to the adoption of an ineffective contraception method. This study aims to evaluate the Italian situation on the perceived quality of contraceptive counselling by patients undergoing abortion. The second aim is to verify if the chosen methods were available for immediate start.

STUDY DESIGN

Multicentric, prospective, non-interventional, non-randomized, non-pharmacological clinical observational study. We analyzed anonymous questionnaires on contraceptive counseling and LARC (Long Acting Reversable Contraceptives) availability and SARC (Short Acting Reversable Contraceptives) prescription at hospital discharge, distributed to women who requested abortion.

RESULTS

1074 participants on 15 hospitals through Italy. 82 % of the interviewees reported that they had received correct information regarding contraception. 74 % of the patients who chose LARC methods reported to have them inserted at the time of abortion. 73 % of women who had chosen a SARC method stated that they had received the prescription before discharge. After contraceptive counselling, we reported a significative reduction of "none or natural methods use" and a significant increase of SARC and LARC use compared to before the abortion.

CONCLUSION

Contraceptive counselling could allow a better contraceptive choice in patient who required abortion and we hope that future strategies will implement LARC choice. We think that a greater availability of LARC at an affordable price at the time of abortion could improve LARC choice. In case of SARC choice, we have to implement the prescription at hospital discharged.

Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis

This article aims to report the comprehensive and up-to-date analysis and evidence of the insertion rate, expulsion rate, removal rate, and utilization rate of immediate placement of intrauterine devices (IUDs) versus delayed placement after artificial abortion. PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang databases were comprehensively searched up to January 12, 2024 for studies that compared immediate versus delayed insertion of IUDs after abortion. The evaluation metrics included the number of IUD insertion after surgical or medical abortions, the frequency of expulsion and removal at 6 months or 1 year, the number of continued usage, pain intensity scores, the number of infections, the duration of bleeding, and instances of uterine perforation during or after IUD insertion. Ten randomized controlled articles were eligible, comprising 11 research projects, of which 3 projects involved the placement of an IUD after surgical abortion, and 8 projects involved the placement of an IUD after medical abortion. This included 2025 patients (977 in the immediate insertion group and 1,048 in the delayed insertion group). We summarized all the extracted evidence. The meta-analysis results indicated that for post-surgical abortions, the immediate insertion group exhibited a higher IUD placement rate than the delayed insertion group. After medical abortions, the immediate insertion group showed higher rates of IUD placement, utilization, and expulsion at 6 months or 1 year. The two groups showed no statistically significant differences in the removal rate, post-insertion infection rate, pain scores during insertion, and days of bleeding during the follow-up period. Compared to delayed placement, immediate insertion of IUDs can not only increase the usage rate at 6 months or 1 year but also enhance the placement rate.

Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE)

INTRODUCTION

Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention.

METHODS AND ANALYSIS

ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622001024730.

Associations between contraceptive availability and rate of subsequent legal abortions in Colombia: A historical cohort analysis

OBJECTIVE

To describe factors associated with subsequent abortions in Colombia and evaluate whether high-efficacy contraceptive availability (IUD) post-index abortion was associated with higher efficacy contraceptive initiation and fewer subsequent abortions within 2 years.

METHODS

The study population comprised patients aged 15-44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2-year follow-up (2017-2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi-square and multivariate logistic regression.

RESULTS

Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017-2019). IUD availability (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.39-1.93) and insurance use (aOR, 5.03; 95% CI, 4.37-5.78) were associated with high-efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22-0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59-6.80) or moderate-efficacy (injection: aOR, 4.21 [95% CI, 3.14-5.62]; oral contraceptive pill: aOR, 4.60 [95% CI, 3.21-6.59]) methods were associated with subsequent abortion.

CONCLUSION

Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.

Educational Multimedia Tool Compared With Routine Care for the Uptake of Postpartum Long-Acting Reversible Contraception in Individuals With High-Risk Pregnancies: A Randomized Controlled Trial

OBJECTIVE

To assess whether an intervention with a multimedia educational tool, compared with routine care, would increase the use of long-acting reversible contraceptives (LARC) at 12 weeks postpartum in individuals with high-risk pregnancies.

METHODS

In this single-center randomized trial, we assigned individuals aged 13-50 years with high-risk pregnancies to either a multimedia educational tool or routine care. Participants were included during pregnancy through postpartum day 1. Those randomized to the multimedia educational tool (MET) group were provided a tablet with the preloaded 3-5-minute multimedia presentation (https://prezi.com/view/jpFrXaPnnxuqRkcI3A4a/), which was viewed without the presence of research staff and resent by secure email every 4 weeks if undelivered. The primary outcome was uptake of LARC (implant or intrauterine device) within 12 weeks of delivery. The secondary outcomes included overall use of any method of contraception and composite maternal and neonatal adverse outcomes. A priori estimates indicated that 380 participants were needed to detect a 40% difference in use of LARC (baseline 40%; alpha=0.05, power=0.8, assumed loss to follow-up 20%). Relative risk (RR) and number needed to treat (NNT), along with 95% CIs, were calculated.

RESULTS

From July 2020 through December 2020, 536 persons were screened and 380 randomized as follows: 190 for the multimedia educational tool and 190 for routine care. Demographic characteristics were similar between groups. The primary outcome-available for more than 90% of participants-was higher in the MET group (32.4%) than in the routine care (RC) group (20.9%) (RR 1.55; 95% CI 1.09-2.21; NNT nine, with 95% CI 5-42). Overall use of contraception was also higher in the MET group than in the RC group (RR 1.16; 95% CI 1.03-1.32).

CONCLUSION

Among individuals with high-risk pregnancies, compared with routine care, use of a multimedia-based educational tool increased the uptake of postpartum LARC by 55%.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04291040.

FUNDING SOURCE

Funded in part by Investigator-Initiated studies of Organon.

Safety of voluntary interruption of pregnancy (VIP) in two healthcare institutions in Medellín, Colombia, in 2019. Historical cohort

Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique used. Materials and Methods: Descriptive study in a historical cohort of women undergoing VIP in two healthcare institutions in Medellín, Colombia, in 2019. Women with pelvic infection and STIs were excluded. Consecutive sampling was used. Sociodemographic, sexual and reproductive health, clinical characteristics of the pregnancy, legal cause of the VIP, characteristics of the care process and complications of the VIP techniques up to post-procedural day 7 were the measured variables. A descriptive analysis was carried out. Results: Overall, 1,520 women were identified as eligible during the study period. Of them, 46 were intervened in other institutions, leaving 1,474 candidates to enter the study. Of them, 30 were excluded because of pelvic or sexually transmitted infections. Ultimately, 1,444 pregnant women were included in the analysis. Risk to the mother’s health was the most frequent legal cause in 94.3% of cases. Ninety-nine percent of women received pre-procedural counseling, and 78.4% agreed to use some form of contraception after VIP. Manual vacuum aspiration (MVA) was used in 95.6% of women and dilation and curettage (D&C) in 4.4%. Complications up to postoperative day 7 occurred in 17.56%, and there were no complications in the MVA group; 80% of women attended the follow-up visit on post-VIP day 7. Conclusions: MVA is a safe procedure which was not associated with complications within the first seven post-VIP days in the studied patients. Prospective studies to assess the safety and cost of the different VIP options are required.

Predictors and Barriers to Post Abortion Family Planning Uptake in Hai District, Northern Tanzania: A Mixed Methods Study

INTRODUCTION

Post Abortion Care (PAC) encompassing family planning counselling and contraception provision is a key strategy to reducing maternal morbidity and mortality especially in countries with restrictive abortion laws. Various factors affect the uptake of PAC modern family Planning (FP) in different settings. This study aimed at determining the prevalence, assessment of factors and barriers to PAC modern FP uptake in Hai district, Northern Tanzania.

METHODS

A mixed-methods study was conducted using an explanatory sequential design. Exit interviews using questionnaires was conducted among 189 women. In-depth interviews were conducted with 26 healthcare providers (HCPs) and 28 women who received PAC in Hai district hospital, Machame hospital and Moshi Specialists health centre in Hai district. Quantitative data was analysed using a Statistical Package for Social Science (IMB SPSS Statistics for Windows version 20.0 (SPSS Inc., Chicago, Ill., USA)). Bivariate and multivariable analyses were applied to estimate the predictors of uptake of PAC modern FP. Thematic content analysis was employed to explore barriers to uptake of post-abortion modern family planning.

RESULTS

The prevalence of uptake of modern family planning following PAC was 59/189(31.2%). 56% of the 189 women who received PAC did not receive counselling services on family planning. Marital status and partner's support were predictors of PAC modern family planning uptake (p=.007 vs. p= <.05, respectively).Misinformation and misconception about modern contraceptives, lack of knowledge and fear of side effects were reported to be the major barriers to uptake of post-abortion family planning. Most women reported to have not received comprehensive family planning information from the HCPs. On the other hand, HCPs perceived their poor counselling skills as the barrier to post-abortion family planning uptake. This study observed poor coordination of PAC services within each visited facility and this was linked to women leaving the facility without family planning counselling and/or contraceptives provision.

CONCLUSION

Suboptimal modern family planning counselling during PAC contributes to the low uptake of contraceptives methods in this setting. Strategies are needed to improve PAC modern family planning services uptake. Strategies such as; provision of counselling skills to HCPs with comprehensive information targeting local contextual misconception and promoting PAC provision as a one-stop service.

Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review

INTRODUCTION

Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC.

MATERIAL AND METHODS

In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively.

RESULTS

We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do.

CONCLUSIONS

Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.

Abortion Surveillance - United States, 2018

PROBLEM/CONDITION

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

PERIOD COVERED

2018.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2018, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2009-2018. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2017 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

RESULTS

A total of 619,591 abortions for 2018 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2009-2018, in 2018, a total of 614,820 abortions were reported, the abortion rate was 11.3 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 189 abortions per 1,000 live births. From 2017 to 2018, the total number of abortions and abortion rate increased 1% (from 609,095 total abortions and from 11.2 abortions per 1,000 women aged 15-44 years, respectively), and the abortion ratio increased 2% (from 185 abortions per 1,000 live births). From 2009 to 2018, the total number of reported abortions, abortion rate, and abortion ratio decreased 22% (from 786,621), 24% (from 14.9 abortions per 1,000 women aged 15-44 years), and 16% (from 224 abortions per 1,000 live births), respectively. In 2018, women in their 20s accounted for more than half of abortions (57.7%). In 2018 and during 2009-2018, women aged 20-24 and 25-29 years accounted for the highest percentages of abortions; in 2018, they accounted for 28.3% and 29.4% of abortions, respectively, and had the highest abortion rates (19.1 and 18.5 per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.6 per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2018 and throughout 2009-2018 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2009 to 2018 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with women in any other age group. From 2009 to 2013, the abortion rates decreased for all age groups and from 2014 to 2018, the abortion rates decreased for all age groups, except for women aged 30-34 years and those aged ≥40 years. In addition, from 2017 to 2018, abortion rates did not change or decreased among women aged ≤24 and ≥40 years; however, the abortion rate increased among women aged 25-39 years. Abortion ratios also decreased from 2009 to 2018 among all women, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with women in any other age group. The abortion ratio decreased for all age groups from 2009 to 2013; however, from 2014 to 2018, abortion ratios only decreased for women aged ≥35 years. From 2017 to 2018, abortion ratios increased for all age groups, except women aged ≥40 years. In 2018, approximately three fourths (77.7%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.2%) were performed at ≤13 weeks' gestation. In 2018, and during 2009-2018, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2018, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (52.1%), followed by early medical abortion at ≤9 weeks' gestation (38.6%), surgical abortion at >13 weeks' gestation (7.8%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 50.0% of abortions were early medical abortions. In 2017, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women were identified to have died as a result of complications from legal induced abortion.

INTERPRETATION

Among the 48 areas that reported data continuously during 2009-2018, decreases were observed during 2009-2017 in the total number, rate, and ratio of reported abortions, and these decreases resulted in historic lows for this period for all three measures. These decreases were followed by 1%-2% increases across all measures from 2017 to 2018.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is a major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Association between contraceptive method chosen after induced abortion and incidence of repeat abortion in Northern Portugal

OBJECTIVES

In Portugal, a country with strong Catholic roots, elective termination of pregnancy at women's request is still stigmatised, especially if it is a repeat abortion. The objectives of this study were to determine the incidence of repeat abortion, taking into account the contraceptive method chosen after the index abortion event, and characterise the risk factors for repeat abortion.

METHODS

This was a retrospective cohort study of 988 women who requested termination of pregnancy during 2015 in a Portuguese tertiary care public hospital. Contraception was given free of charge after the index event. The occurrence of a repeat induced abortion was evaluated during a 24 month follow-up period.

RESULTS

Forty-nine (5.0%) of the 988 women had a repeat abortion. Users of long-acting reversible contraception (LARC) had fewer repeat abortions compared with users of non-LARC methods. Overall repeat abortion was 0.8% in subcutaneous contraceptive implant users, 1.5% in intrauterine contraceptive device (IUCD) users, 2.8% in vaginal ring users and 5.8% in oral contraceptives users (p < 0.05). Cox hazards ratio (HR) analysis showed that method choice after abortion correlated significantly with the probability of repeat abortion (p < 0.05). Using women choosing oral contraception as the reference group, the HRs (95% CIs) for repeat abortion were as follows: IUCD 0.282 (0.084, 0.942), contraceptive implant 0.142 (0.019, 1.050), vaginal ring 0.508 (0.175, 1.477).

CONCLUSION

Even though highly effective contraceptive methods are freely accessible in Portugal, other challenges must be managed to improve outcomes, such as a timely, patient-centred counselling approach.

Association between the use of free-of-charge intrauterine devices and a history of induced abortion: a retrospective study

Background

To determine whether use of intrauterine device (IUD) is influenced by a history of induced abortion and the type of contraceptives used until costs are covered.

Methods

We analyzed data from 301 female residents in Mecklenburg-West Pomerania, an economically challenged community. The women, aged between 20 and 35 years, were entitled to receive unemployment benefits, and had access to free-of-charge oral contraceptives, ring or IUD. Cross-sectional data were analyzed using logistic regression.

Results

There were 112 (37.2%) women with a history of induced abortion, and 46 (15.3%) reported exclusively using less effective contraceptives (e.g. condoms). In a univariate logistic regression, use of an IUD was associated with a history of having had an induced abortion. Furthermore, uptake of an IUD was associated with women who had, until costs were covered, exclusively choice to use less effective contraceptives (OR = 3.281, 95% CI: 1.717; 6.273). Both associations remained significant in a multivariate model.

Conclusions

Free contraceptives provided to women receiving unemployment benefits may increase the use of IUDs, especially among those with a history of an induced abortion and those using less effective contraceptives.

Association Between Women's Use of Long-Acting Reversible Contraception and Declining Abortion Rates in New Zealand

Background: To investigate the hypothesis that increased uptake of long-acting reversible contraception (LARC) by women played a role in the declining abortion rates observed in New Zealand between 2008 and 2014. Materials and Methods: This quantitative ecological study analyzed routinely collected national data pertaining to abortion numbers, contraceptive prescriptions, and census population estimates for the period 2004-2014. Annual prescription and prevalence rates (per 1000 women) were calculated for short- and long-acting methods to investigate changes over time. Poisson's regression was used to (1) test whether the abortion rate changed by year; (2) whether 2010 (when the contraceptive implant became subsidized) was a significant point of change; and (3) test the relationship between declining abortions and patterns of contraceptive use. Results: Estimated LARC prevalence increased from 2009 to 2014, with a corresponding decrease observed in prescription of short-acting methods. The declining abortion rate accelerated each year from 2008 to 2014 (with a faster decline from 2010 to 2014), but 2010 was not a significant point of change. Three factors had statistically significant associations with declining abortion rates (p < 0.01): year (acting as a surrogate for all social changes), women's use of the levonorgestrel (LNG)-implant, and the combined model: use of the LNG-implant and copper intrauterine device (CuIUD) had the best fit (using Akaike's Information Criterion), indicating that this variable explained more of the year-to-year variability in abortion rates. Conclusions: The shift toward women's increased use of the two publically funded LARC methods (LNG-implants and CuIUD) was significantly associated with the declining abortion rates in New Zealand.

Postabortion and Postpartum Intrauterine Device Provision for Adolescents and Young Adults

Adolescents are at high risk for unintended pregnancy and rapid repeat pregnancy, both of which can be associated with negative health and social outcomes. Intrauterine device (IUD) use has been shown to decrease unintended pregnancy and rapid repeat pregnancy. Evidence supports IUD insertion postabortion and postpartum as safe and practical for nearly all women, including adolescent and young adult women. Providers of adolescent gynecology can play an important role in decreasing repeat and unintended pregnancy among adolescents by increasing access to IUDs, reducing barriers to care, and providing IUDs immediately postabortion and postpartum.

Trends and determinants of postabortion contraception use in a Canadian retrospective cohort

OBJECTIVES

We aim to describe demographic trends associated with postabortion contraceptive choice, characteristics of intrauterine device (IUD) users and relation to subsequent abortion.

STUDY DESIGN

Our retrospective chart review study included all patients obtaining an abortion from 2003 to 2010 at the primary service provider in the Interior Health Region of British Columbia, tracking each patient for 5 years to detect subsequent abortion. We used descriptive statistics to analyze demographic trends and logistic regression to examine determinants of choosing an IUD and likelihood of subsequent abortion per contraceptive method.

RESULTS

Our study cohort included 5206 patients, 1247 (24.0%) of whom chose an IUD. Patients increased IUD use from 10.14% to 45.74% of the cohort over the study period. Mean age of those choosing an IUD significantly decreased over the study period [30.9±7.3 years in 2003 to 26.2±6.5 years in 2010 (p<.001)]. In multivariable analysis, factors associated with choosing an IUD postabortion were prior delivery [aOR=2.77 (95% CI 2.40-3.20)] and being older than 20 years [20-29 years: AOR=1.87 (1.51-2.32); or 30+ years: AOR=1.96 (1.54-2.50)]. Patients choosing an IUD were less likely to have a subsequent abortion compared to those selecting oral contraceptives [aOR=1.96 (95% CI 1.54-2.52)] or depomedroxyprogesterone acetate [aOR=1.84 (95% CI 1.36-2.49)].

CONCLUSIONS

We found an increasing trend of choosing an IUD after an abortion in our population, especially among youth. Patients who chose an IUD postabortion were less likely to have a subsequent abortion over the next 5 years.

IMPLICATIONS

An important strategy for reducing subsequent abortion is to ensure that those seeking abortion have accurate information on the comparative effectiveness of postabortion contraception methods. Educational efforts, alongside removal of cost and other barriers, will contribute to the prevention of subsequent abortion and improve equitable access to IUDs among the population.

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion

OBJECTIVES

To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation.

STUDY DESIGN

We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome.

RESULTS

Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant.

CONCLUSION

About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles.

IMPLICATIONS

Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.

Contraception after Abortion and Risk of Repeated Unintended Pregnancy among Health Plan Members

CONTEXT

Optimizing access to effective contraception at the time of abortion can reduce repeated unintended pregnancies.

OBJECTIVE

To assess contraception initiation and repeated unintended pregnancies among women receiving abortions in Kaiser Permanente Northern California (KPNC) facilities and through outside contracted facilities.

DESIGN

A retrospective cohort study was conducted using a randomized proportional sample of women aged 15 to 44 years having abortions in KPNC, to determine contraception initiation within 90 days. Demographic and clinical characteristics (age, race/ethnicity, gravidity, parity, contraceptive method initiated, and pregnancies within 12 months) were collected from electronic health records. Descriptive statistics, χ² tests, t-tests, and logistic regression models assessed predictors of long-acting reversible contraception (LARC) initiation and having another unintended pregnancy within 12 months of abortion.

RESULTS

Women having abortions from contracted facilities were significantly less likely to initiate LARC within 90 days compared with those receiving abortions in KPNC facilities (11.99% vs 19.10%, p = 0.012). Significant factors associated with 90-day LARC initiation included abortions in KPNC facilities (adjusted odds ratio [aOR] = 1.87, p = 0.007) and gravidity of 3 or more. Women initiating short-acting or no contraception were significantly more likely to have an unintended pregnancy within 12 months of the abortion than those initiating LARC (aOR = 3.66, p = 0.005; no contraception vs LARC, aOR = 3.75, p = 0.005).

CONCLUSION

In response to this study, KPNC now provides reimbursement for LARC in all outside abortion contracts, internalized more abortions in KPNC facilities, and strengthened clinical recommendations for immediate, effective postabortion contraception, especially LARC.

The Association Between Multiple Abortions Within 1 Year and Previous Postabortal Desired Contraception at an Urban, Public Hospital

Objectives: To determine the proportion of women undergoing multiple abortions within 1 year at an urban, public hospital and the association with desired contraception after the index abortion. Materials and Methods: We conducted a retrospective analysis of all women undergoing abortion up to 13 weeks and 6 days gestation at Stroger Hospital from June 1, 2012 to May 31, 2014. We examined the proportion of women with additional abortions up to 1 year after the index abortion and contraception desired at the index abortion. We also collected data about Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infection in surgical abortion patients, to assess suitability for intrauterine device insertion immediately postabortion. Results: Of the 5,104 women with an abortion in the study period, 720 (14.1%) had at least one additional abortion within 1 year. Among women with multiple abortions, 153 (21.3%) selected Tier 1 contraception, 359 (49.8%) Tier 2, 103 (14.3%) Tier 3, and 105 (14.6%) were undecided or desired no method. The contraception desired at the index abortion did not differ significantly between women with and without subsequent abortions (p = 0.107). CT/GC coinfection and CT infection alone were associated with having multiple abortions over the 1-year period (p = 0.020 and p = 0.006). Conclusions: Among women presenting for abortion at an urban, public hospital, desired contraception did not differ significantly between women with multiple abortions versus one abortion within 1 year, but prevalence of CT/GC did. Women at high risk for multiple abortions may benefit from immediate postabortion IUD insertion to avoid unintended pregnancy, provided risk of infection is carefully evaluated.

Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial

BACKGROUND

With advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge.

METHODS

This was a pilot randomised controlled trial. Prior to their abortion visit, participants were randomised to the intervention message, a standardised notification about the availability, effectiveness and safety of long-acting (LARC) and short-acting reversible contraception (SARC) on the day of the abortion, or to the control message, a reiteration of appointment logistics without information about contraception. At the visit, participants completed a pre-procedure survey to assess contraceptive knowledge and usefulness of the intervention. The primary outcome was knowledge of LARC availability immediately after surgical abortion. A secondary outcome was contraceptive method uptake.

RESULTS

We enrolled 234 subjects. The pre-visit telephone notification improved knowledge that LARC is available immediately after surgical abortion (71.3% vs 50.9%, P<0.01). Participants in both study arms found the telephone notifications useful. Post-abortion contraceptive method choice did not differ between study arms.

CONCLUSIONS

Advance notice about contraception was acceptable to surgical abortion patients and improved their contraceptive knowledge.

TRIAL REGISTRATION NUMBER

NCT02836561.

Factors associated with initiating long-acting reversible contraception immediately after first-trimester abortion

OBJECTIVE

The objective was to identify predictors of postabortion long-acting reversible contraception (LARC) initiation to increase providers' understanding of motivators of contraceptive choices.

STUDY DESIGN

We prospectively enrolled a cohort of women having abortions at <13 weeks' gestational age who were eligible to receive no-cost contraceptive methods immediately postprocedure (N=1662) to evaluate the demographic and reproductive factors associated with choosing and receiving a long-acting contraceptive versus a short-acting method. We used stepwise logistic regression to identify independent predictors of LARC initiation.

RESULTS

During the study period, 1072 (64.5%) chose an immediate postabortion LARC method and 590 (35.5%) chose another method. Compared to the group of women who chose a non-LARC method, women who chose a LARC method were more likely to have a surgical abortion and were younger, more likely to be Hispanic, more likely to live greater than 70 miles from the clinic, more likely to have a nonurban address and less likely to have had a prior abortion.

CONCLUSIONS

We found that the differences in the demographic and reproductive factors of women choosing and receiving postabortion LARC were those which have been shown to be associated with difficulty in accessing contraception. Providers should offer a full range of contraceptive options to women immediately postabortion.

IMPLICATIONS

Postabortion LARC is more likely to be utilized by women from groups who have been shown to have difficulty accessing traditional family planning clinical care: those who are young, do not live in a city and are from groups with recognized health disparities. Offering postabortion LARC increases the options for these women.

Bleeding pattern difference between levonorgestrel intrauterine system and copper intrauterine devices inserted immediately post-abortion: a multicenter, prospective, observational cohort study in Chinese women

BACKGROUND

To describe the bleeding pattern (primary outcome), side effects, treatment satisfaction and 6 month continuity rates associated with the 52 mg levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD) inserted immediately after abortion.

METHODS

This multicenter, prospective, observational cohort study enrolled healthy women (aged ≥18 years) inserted with LNG-IUS or Cu-IUD immediately after first-trimester surgical abortion and followed up to 6 months. Bleeding pattern was obtained through daily patient bleeding diaries.

RESULTS

From 2013 to 2014, we enrolled 512 women (LNG-IUS = 312 [median age: 32.0 years] and Cu-IUD = 200 [median age: 30.0 years]) from nine Chinese centers. LNG-IUS resulted in a significantly lower number of bleeding/spotting days in the second 90 day reference period compared with Cu-IUD (median 14.5 vs. 18.0 days, p < .0001). Amenorrhea rate (no bleeding/spotting day in the second 90 day reference period) and no menstrual bleeding rate (absence of bleeding days in the second 90 day reference period) were significantly higher in LNG-IUS compared to Cu-IUD (13.9% vs. 0% and 39.5% vs. 0%; p < .001 for all). No dysmenorrhea was higher at the last follow-up in LNG-IUS users than Cu-IUD users (81.2% vs. 76%; p = .0047). Both treatments had a high satisfaction rate among women at both the follow-up visits, and the majority of them continued with the treatment. The rates of adverse events (e.g. oligomenorrhea, amenorrhea) in the LNG-IUS and Cu-IUD groups were 77.2% and 44.5% (p < .0001), respectively.

CONCLUSION

LNG-IUS post-abortion shows better bleeding patterns, and reduced dysmenorrhea and bleeding amount, but with a similar safety profile compared with Cu-IUD. ClinicalTrials.gov identifier: NCT01958684.

Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).

Postabortion Contraceptive Use and Continuation When Long-Acting Reversible Contraception Is Free

OBJECTIVE

To compare preference for long-acting contraception (LARC) and subsequent use, year-long continuation, and pregnancy among women after induced abortion who were and were not eligible to participate in a specialized funding program that provided LARC at no cost.

METHODS

Between October 2014 and March 2016, we conducted a prospective study of abortion patients at Planned Parenthood in Austin, Texas (located in Travis County). We compared our primary outcome of interest, postabortion LARC use, among women who were eligible for the specialized funding program (low-income, uninsured, Travis County residents) and two groups who were ineligible (low-income, uninsured, non-Travis County residents, and higher income or insured women). Secondary outcomes of interest included preabortion preference for LARC and 1-year continuation and pregnancy rates among the three groups.

RESULTS

Among 518 women, preabortion preference for LARC was high among all three groups (low-income eligible: 64% [91/143]; low-income ineligible: 44% [49/112]; and higher income 55% [146/263]). However, low-income eligible participants were more likely to receive LARC (65% [93/143] compared with 5% [6/112] and 24% [62/263], respectively, P<.05). Specifically, after adjusting for age, race-ethnicity, and education, low-income eligible participants had a 10-fold greater incidence of receiving postabortion LARC compared with low-income ineligible participants (incidence rate ratio 10.13, 95% confidence interval [CI] 4.68-21.91). Among low-income eligible and higher income women who received postabortion LARC, 1-year continuation was 90% (95% CI 82-97%) and 86% (95% CI 76-97%), respectively. One-year pregnancy risk was higher among low-income ineligible than low-income eligible women (hazard ratio 3.28, 95% CI 1.15-9.31).

CONCLUSION

Preference for postabortion LARC was high among all three eligibility groups, yet women with access to no-cost LARC were more likely to use and continue these methods. Low-income ineligible women were far more likely to use less effective contraception and become pregnant. Specialized funding programs can play an important role in immediate postabortion contraceptive provision, particularly in settings where state funding is limited.

[Post-abortion contraception]

OBJECTIVE

To establish guidelines of the French National College of Gynecologists and Obstetricians about post-abortion contraception.

MATERIALS AND METHODS

A systematic review of the literature about post-abortion contraception was performed on Medline and Cochrane Database between 1978 and March 2016. The guidelines of the French and foreign scientific societies were also consulted.

RESULTS AND DISCUSSION

After an abortion, if the woman wishes to use a contraception, it should be started as soon as possible because of the very early ovulation resumption. The contraception choice must be done in accordance with the woman's expectations and lifestyle. The contraindications of each contraception must be respected. The long-acting reversible contraception, intra-uterine device (IUD) and implant, could be preferred (grade C) as the efficacy is not dependent on compliance. Thus, they could better prevent repeat abortion (LE3). In case of surgical abortion, IUD should be proposed and inserted immediately after the procedure (grade A), as well as the implant (grade B). In case of medical abortion, the implant can be inserted from the day of mifépristone, the IUD after an ultrasound examination confirming the success of the abortion (no continuing pregnancy or retained sac) (grade C).

A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial

OBJECTIVE

To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion.

METHODS

We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized.

PRIMARY OUTCOME

uptake of LARC within four weeks of abortion.

SECONDARY OUTCOMES

uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes.

RESULTS

In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04).

CONCLUSION

Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling.

PRACTICE IMPLICATIONS

A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.

Contraceptive counselling of women seeking abortion - a qualitative interview study of health professionals' experiences

OBJECTIVES

A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionalś experiences of providing contraceptive counselling to women seeking an abortion.

METHODS

We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis.

RESULTS

Three clusters were identified: 'Complex counselling', 'Elements of counselling' and 'Finding a method'. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method.

CONCLUSIONS

HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

Associations Between Abortion Services and Acceptance of Postabortion Contraception in Six Indian States

Women receiving induced abortions or postabortion care are at high risk of subsequent unintended pregnancy, and intervals of less than six months between abortion and subsequent pregnancy may be associated with adverse outcomes. This study highlights the prevalence and attributes of postabortion contraceptive acceptance from 2,456 health facilities in six major Indian states, among 292,508 women who received abortion care services from July 2011 through June 2014. Eighty‐one percent of the women accepted postabortion contraceptive methods: 53 percent short‐term, 11 percent intrauterine devices, and 16 percent sterilization. Postabortion contraceptive acceptance was highest among women who were aged 25 years and older, received first‐trimester services, received induced abortion, attended primary‐level health facilities, and had medical abortions. Doctors receiving post‐training support were more likely to offer contraceptives, but no association was observed between such support and acceptance of IUDs or sterilization. Comprehensive service‐delivery interventions, including ensuring availability of skilled providers and contraceptive commodities, offering clinical mentoring for providers, identifying and addressing provider bias, and improving provider counseling skills, can increase postabortion contraceptive acceptance and reduce unintended pregnancy.

Strengthening Postabortion Family Planning Services in Ethiopia: Expanding Contraceptive Choice and Improving Access to Long-Acting Reversible Contraception

Where unmet need for the safest, most effective, and long-acting reversible contraceptives (LARCs) is very high, the health system and partners need to implement problem-solving, locally feasible, and comprehensive family planning delivery strategies. Because young and unmarried women are most at risk for unintended pregnancy and repeat abortion due to poor access to contraceptive services, postabortion family planning (PAFP) is a key component in such strategies. In Southern Nations, Nationalities, and People's Region, Ethiopia, Ipas implemented health system strengthening efforts from fiscal year (FY) 2010 (July 2009 to June 2010) to FY 2014 (July 2013 to June 2014) to improve the quality of PAFP services and expand method choice in 101 public facilities. The intervention significantly improved PAFP uptake at the project sites. Specifically, the proportion of abortion clients receiving LARCs progressively improved during the intervention period. The proportion of abortion clients who left the facilities with a contraceptive method increased from 58% in FY 2010 to 83% in FY 2014. The share of method mix for LARCs rose from 2% in FY 2010 to 55% in FY 2014, while the share for condoms, injectables, and oral contraceptives declined from 98% to 45%. Implant use rose from 2% in FY 2010 to 43% in FY 2014, while the use of intrauterine devices increased from 0.1% in FY 2010 to 12% in FY 2014. A larger proportion of PAFP users received LARCs at health centers, where midwives and nurses are the primary providers, than at hospitals (59% versus 37%, respectively). A broader method mix can satisfy clients with a variety of needs, a key factor for higher uptake of more effective methods and program success. Further evidence-based interventions need to be implemented to improve the quality of PAFP in a feasible and replicable strategy that addresses unmet need for modern contraceptive methods.

Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION:

SUMMARY STATEMENTS

1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Acceptance of family planning methods by induced abortion seekers: An observational study over five years

BACKGROUND

Prior to legalization of abortion, induced abortions were performed in an illegal manner and that resulted in many complications hence abortion was legalized in India in 1971 and the number of induced abortions has been gradually increasing since then. One way of preventing abortions is to provide family planning services to these abortion seekers so that same is not repeated. The study was performed to find out the acceptance of contraception after abortion.

METHODS

A prospective study was performed over a period of five years from 2010 to 2014. The study group included all the cases reporting for abortion. A proforma was filled in detail to find out the type of contraception being used before pregnancy and acceptance of contraception after abortion. The existing facilities were also evaluated.

RESULTS

1228 abortions were performed over a period of five years. 94.5% of abortions were during the first trimester. 39.9% had not used any contraceptive before, contraceptives used were natural and barrier which had high failure. The main indication for seeking abortion was failure of contraception and completion of family. 39.6% of patients accepted sterilization as a method of contraception. The existing post abortion family planning services are inadequate.

CONCLUSION

Post abortion period is one which is important to prevent subsequent abortions and family planning services after abortion need to be strengthened.

Comparison of uptake of long-acting reversible contraception after abortion from a hospital or a community sexual and reproductive healthcare setting: an observational study

BACKGROUND

Uptake of the most effective long-acting reversible methods of contraception (LARC) immediately after abortion has been shown to reduce a woman's risk of further abortion. We aimed to compare the uptake of LARC at abortion services from a hospital department of obstetrics and gynaecology and a specialist contraceptive setting of a community sexual and reproductive health (SRH) service within the same city.

METHODS

Retrospective database review of women (n=2473) requesting abortion who were assessed at either a community SRH service or a hospital department of obstetrics and gynaecology, in the same UK city over a period of 1 year. The main outcome measures were immediate post-abortal uptake of LARC from each site.

RESULTS

A higher proportion of women assessed at the SRH service received LARC after abortion [50.2%; 95% confidence interval (CI) 0.47-0.53%] compared to those attending the hospital site (39.2%; 95% CI 0.36-0.42%; p<0.0001). Amongst women having an outpatient early medical abortion, LARC uptake at the SRH was twice that of the hospital setting (48.4% vs 23.3%; p<0.0001).

CONCLUSIONS

Higher uptake of immediate post-abortal LARC was observed amongst women who were assessed at the specialist contraceptive service in the community SRH setting compared to the hospital setting. Further research is required to determine the reasons for these observations since all abortion services should provide the same high-quality contraceptive service to women undergoing abortion.

Adolescent health experience after abortion or delivery (AHEAD) trial: formative protocol for intervention development to prevent rapid, repeat pregnancy

BACKGROUND

There is a high unmet need for modern contraception among adolescents, and adolescent girls who have already been pregnant are especially vulnerable to a rapid, repeat pregnancy (defined as a subsequent pregnancy within two years). The Adolescent Health Experience after Abortion or Delivery (AHEAD) trial will design, pilot, finalize, and ultimately evaluate an intervention targeted at reducing rapid repeat pregnancy. This protocol presents the methods for the first phase--formative research to identify key determinants of contraceptive use and rapid, repeat unintended pregnancy among adolescents.

METHODS/DESIGN

The determinants of adolescent pregnancy are known to vary by context; therefore, a dissimilar set of three countries will be selected to enable evaluation of the intervention in diverse cultural, political and economic environment, and to allow the intervention to be tested with a fuller range of ever-pregnant adolescents, including those who have chosen to terminate their pregnancy as well as those who are mothers. We will also consider marital status in settings where it is common for adolescents to marry. Focus group discussions (FGDs) will be conducted to examine barriers and facilitators to using contraception; preferred methods of overcoming these barriers; and perceptions of the services and information received. Key informant (KI) interviews will take place with various cadres of healthcare providers, health and education officials, and members of key youth and health organizations that work with adolescents. These interviews will focus on perceptions of pregnant adolescents; perceived information, skills, and motivations required for adolescent uptake of contraception; and experiences, challenges, and attitudes encountered during interactions.

DISCUSSION

The findings from this first formative phase will be used to develop an intervention for preventing rapid, repeat unintended pregnancy among adolescents. This intervention will be piloted in a second phase of the AHEAD trial.

Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context

Objective

To examine experiences of contraceptive care from the perspective of health professionals and women seeking abortion, in the contexts of hospital gynaecology departments and a specialist sexual and reproductive health centre (SRHC).

Materials and methods

We conducted in-depth semistructured interviews with 46 women who had received contraceptive care at the time of medical abortion (gestation≤9 weeks) from one SRHC and two hospital gynaecology-department-based abortion clinics in Scotland. We also interviewed 25 health professionals (nurses and doctors) involved in abortion and contraceptive care at the same research sites. We analysed interview data thematically using an approach informed by the Framework method, and comparison was made between the two clinical contexts.

Results

Most women and health professionals felt that contraceptive counselling at abortion was acceptable and appropriate, if provided in a sensitive, nonjudgemental way. Participants framed contraceptive provision at abortion as significant primarily as a means of preventing subsequent unintended conceptions. Accounts of contraceptive decision making also presented tensions between the priorities of women and health professionals, around ‘manoeuvring’ women towards contraceptive uptake. Comparison between clinical contexts suggests that women's experiences may have been more positive in the SRHC setting.

Conclusions

Whilst abortion may be a theoretically and practically convenient time to address contraception, it is by no means an easy time to do so and requires considerable effort and expertise to be managed effectively. Training for those providing contraceptive care at abortion should explicitly address potential conflicts between the priorities of health professionals and women seeking abortion.

Implications

This paper offers unique insight into the detail of women and health professionals' experiences of addressing contraception at the time of medical abortion. The comparison between hospital and community SRHC contexts highlights best practise and areas for improvement relevant to a range of settings.

Rural women are more likely to use long acting contraceptive in Tigray region, Northern Ethiopia: a comparative community-based cross sectional study

Background

In the latest report of Ethiopian Demographic and Health Survey (EDHS) 2011, the maternal mortality ratio (MMR) was estimated at 676/100,000 live births, with total fertility rate at 4.8 and contraceptive prevalence rate at 29 %. Knowledge and utilization of long acting contraceptive in the Tigray region are low. This study aims at comparing and identifying factors related to the utilization of long acting contraceptive in urban versus rural settings of Ethiopia.

Methods

A comparative community-based cross-sectional study, comprised of quantitative and qualitative methods, was conducted among 1035 married women in Wukro (urban area) and Kilteawlaelo district (rural area) in March, 2013. Stratified sampling technique was employed to approach the study participants. Data were analyzed using SPSS version 20. Multiple logistic regression analysis was used to identify the respective effect of independent predictors on utilization of long acting contraceptive.

Results

The proportion of long acting contraceptive use among the respondents was 19.9 % in the town of Wukro and 37.8 % in the district of Kilteawlaelo. Implanon was the most common type of contraceptive used in both districts, urban (75 %) and rural (94 %). The odds of using the long acting contraceptive method were three times higher among married women in the rural areas as compared with the urban women [AOR = 3. 30; 95 %, CI:2.17, 5.04]. No or limited support from male partners was an obstacle to using long acting contraceptive method [AOR = 0. 24, 95 of CI: 0.13, 0.44]. Moreover, married women whose partner did not permit them to use long acting contraceptive [AOR = 0. 47, 95 % of CI: 0.24, 0.92] and women who attended primary education [AOR = 0.24, 95 %, CI: 0.13, 0.44] were significantly associated with long acting contraceptive use.

Conclusion

Overall, the proportion of long acting contraceptive use has found to be low. Rural women were more likely to use long acting contraceptives as compared to urban women. Moreover, educational status and the partner’s permission to use contraception could influence the utilization of long acting contraceptives.

Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial

BACKGROUND

Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates.

METHODS

We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates.

FINDINGS

Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85).

INTERPRETATION

The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits.

FUNDING

William and Flora Hewlett Foundation.